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SAN JOAQUISOUNTY ENVIRONMENTAL HEALTH *ARTMENT <br />cF,RVTrF. REOUEST <br />Type of Business or Property FACILITY ID # <br />SERVICE REQUEST # <br />Ext tr GAS Sr.�n� 2 <br />?� 5� C� <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />Il t UL �, -V tS <br />SERVICE CODE: _ <br />FACILITY NAME RD � D� <br />�(/[ <br />Fee Amount: �' C `Q <br />SITE'A/DDR,ESS <br />0�� � <br />Payment Type ✓ Invoice # <br />Code <br />T '7 Street Number <br />Direction Street Name <br />Ci <br />Zi <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />5 A Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />ExT. <br />PHONE #t <br />APN # <br />- �3 <br />LAND USE APPLICATION # <br />('2 23 2- 5- <br />z39- 03� <br />PHONE 02 EXT. <br />26 4- <br />BOS DISTRICT <br />LOCATION CODE <br />( 2-6')) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR�'P� -�j �� CHECK if BILLING ADDRESS <br />PHONE # EXT. <br />BUSINESS NAME etc SS En '}� g/, (. S 7O <br />— <br />HOME or MAILING ADDRESS FAX # <br />2��� EJCt2G 12 �NI (IrG6) 372-' 376 <br />CITY �l�L tIC� IM e Vn� STAT ZIP ! (� C <br />v <br />Wes;. .J <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: &24.n== DATE: /�!b-2 3-09 <br />PROPERTY / BUSINESS OWNER 1:1 OPERATOR/ MANAGER 13 OTHER AUTHORIZED AGENT 0 eo VTC <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available &lad �t the Santime it is <br />provided to me or my representative. 1�l''/E��Y.—MEN <br />n <br />TYPE OF SERVICE REQUESTED: 7 p <br />COMMENTS: 8 Lfl�s <br />SAN JOAQUIN COUNTY <br />HEALTH DEPARTMENT NT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE:/72 <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: _ <br />P I E. <br />(• <br />Fee Amount: �' C `Q <br />Amount Paid 3 (5 D U <br />Payment ate 0 �� O <br />Payment Type ✓ Invoice # <br />Check # <br />Received By: <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />